Asthma disproportionately burdens minority and low-income pediatric populations, and these disparities have persisted among high-risk children despite the dissemination of NHLBI asthma management guidelines more than a decade ago. Previous investigations suggest that asthma guidelines-based care has not translated to high-risk children living in rural regions. Asthma-related morbidity and non-adherence to asthma guidelines is prevalent among high-risk rural children living in the Mississippi Delta region of Arkansas, an impoverished and medically underserved region of the United States. Large-scale interventions to decrease asthma burden among high-risk rural children have not been designed, and interventions designed for other populations are not feasible due to distance and travel barriers and lack of subspecialty asthma services inherent to rural communities. The overall goal of the proposed project is to decrease asthma health outcomes disparities among high-risk children living in a rural, medically underserved environment. To address this goal, we propose conducting a cluster randomized trial with 540 children, ages 4-17 years, to implement a school-based telemedicine intervention in rural public school districts. The school-based intervention will provide comprehensive asthma education via telemedicine to rural children with asthma, their caregivers and school nurses; prospectively monitor asthma symptoms and lung function via telemedicine; and provide primary care providers with treatment prompts according to nationally published asthma guidelines. We hypothesize that children receiving school-based asthma education and monitoring via telemedicine in conjunction with a provider treatment prompt will have decreased asthma-related morbidity as compared to children receiving usual care. The aims of the project will: 1) examine the efficacy of a school-based asthma telemedicine intervention in improving asthma-related health outcomes in an intervention group compared to a usual care group; 2) examine the effects of a school-based asthma telemedicine intervention on asthma self-management skills; and 3) determine the cost of the intervention. Telemedicine will allow for the utilization of proven technology to deliver a state-of-the-art asthma intervention in a high-risk population and will significantly reduce challenges associated with distance and travel barriers inherent to rural communities. An innovative telemedicine approach to improve asthma health outcomes among high-risk rural children has high impact potential because findings from the proposed intervention will directly inform public health strategies to implement large-scale telemedicine services in a school-based setting. The intervention will have direct applicability to other high-risk asthma populations in rural and medically underserved regions and can be translated to school-based health intervention strategies to target other chronic health conditions.